Dive Brief:

• A New York health plan and one of its former executives have agreed to pay $100 million to settle allegations they defrauded the federal government by inflating the risk scores of beneficiaries in privatized Medicare plans.
• Through a coding subsidiary, New York-based Independent Health reported unsupported diagnoses to inflate risk adjustment payments for its Medicare Advantage members, submitting thousands of false claims that led to millions of dollars in fraudulent reimbursement, according to the Department of Justice.
• It’s one of the largest recent False Claims Act settlements for an insurer, and brings to a close a 12-year whistleblower lawsuit.

Trendline

The evolution of electronic health records

After federal incentives spurring widespread adoption more than a decade ago, EHRs have become the bedrock of clinical data in the healthcare industry.

Dive Insight:

In MA, the government pays insurers a set amount to manage the care of Medicare beneficiaries. Payments are adjusted based on risk scores representing beneficiaries demographics, location and health needs, so plans are generally paid more for caring for sicker members.

MA plans have grown substantially in recent years to cover more than half of all Medicare members. That growth has intensified concerns about insurers jacking up government reimbursement through upcoding — or sniffing out and reporting additional medical diagnoses for their members in return for higher risk codes.

Upcoding can...

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